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1 Name Address Social Security # Date of Birth City State Zip Sex Marital Status Home Phone # Work Phone # Cell# Employer Occupation Race: Employed: Full Time Part Time Retired Student: Full Time Part Time Person to Notify in an Emergency Relationship Phone Number Primary Care Physician Referring Physician Insurance Information: Primary Insurance Are you the policyholder? Yes No (*this information is NOT on the card*) If not, policyholder s name? Relationship to Patient Policyholder Date of Birth Policyholder Employer Secondary Insurance Are you the policyholder? Yes No If not, policyholder s name? Relationship to Patient Policyholder Date of Birth Policyholder Employer Insurance Authorization & Information Release I hereby authorize St. Agnes Healthcare to release information from my records to persons who have need for this information such as insurance companies, doctors, and other agencies or professionals involved in my care. St. Agnes Healthcare personnel are authorized to determine which persons or agencies are in need of such information. I hereby authorize Medicare, Medicaid and/or any insurance company(s) to pay St. Agnes Healthcare directly for services provided. I agree to accept financial responsibility for services provided at St. Agnes Healthcare for the patient. Signature: Date: Notice of Privacy Practices/Financial Policy Receipt: I hereby acknowledge that I have received a copy of the St. Agnes Healthcare Joint Notice of Privacy Practices & the Maryland Surgeons Financial Policy. Signature: Date:

2 Acknowledgement and Consent Patient Name PLEASE PRINT Date of Birth By signing this form, I consent to MARYLAND SURGEONS/St. Agnes Healthcare use and disclosure of protected health information about me to the persons listed below. I understand that I have the right to revoke this consent in writing, except where MARYLAND SURGEONS/St. Agnes Healthcare has already made disclosures in trust on my prior consent. Signature Date Please list family members or others with whom we may discuss your medical information or account information. Please designate by your X in the appropriate column, which information we may discuss with each party listed. Name Relationship Medical Account Other Health Care Providers GYN Name Phone Fax Gastroenterologist Phone Fax Oncologist Phone Fax So that we may better assist you in the future, please provide the following: address: Pharmacy: City: Pharmacy Phone #:

3 Name: Primary Care Physician: Date of Birth: Age: Referring Physician: 1. Reason for visit: Work related? 2. Do you have allergies to medications? No Yes List medication & reaction (i.e. rash, trouble breathing) 3. Any allergy to: latex; tape; betadine scrub; contrast (IV dye)? (check item if allergic) 4. Current medications (include dosage): 5. Past or present medical problems: (check all that apply) Anemia Asthma Cancer Chronic cough Chronic lung disease Cirrhosis of the Liver Colon cancer Colon polyps Crohn s Disease Diabetes Diverticulitis DVT Emphysema Frequent UTI/ Kidney Infection Heart Attack Heart murmur/ Rhuematic Fever Hepatitis Hiatal hernia High blood pressure High cholesterol High triglycerides Irregular heart beat Irritable bowel syndrome Kidney disease/failure Multiple Sclerosis Ovarian cyst Pancreatitis Parkinson s disease Phlebitis Pneumonia Pulmonary embolism Seizures Skin cancer Stomach/ duodenal ulcer Stroke or paralysis Thyroid disease Transfusions Ulcerative colitis 6. Past surgeries: NONE Appendectomy Gallbladder Hernia Repair Colon Resection Other: 7. Have you or any family member ever had a problem with anesthesia? No Yes 8. Family history: Father Mother Brother Sister a) Heart Trouble: b) Cancer: c) Diabetes: 9. Social history: a) Tobacco use: never smoked smoker: how much ex-smoker: quit when b) Alcohol use: none rarely often daily c) Occupation:

4 Patient Name: Date Of Birth: REVIEW OF SYSTEMS Please circle any illness or problems that you are currently experiencing. GENERAL NONE Weight gain, Weight loss, other EYES NONE Change in vision, poor vision, other EAR/NOSE/THROAT NONE Sleep apnea, hearing loss, other: RESPIRATORY NONE Shortness of breath, wheezing, other: CARDIOVASCULAR NONE Chest pain with activity, pain in legs with walking, Date of last EKG, Stress Test, Echo, and/or Cardiac Cath: GASTROINTESTINAL NONE Blood in stool, yellow eyes/ skin, other: GENITOURINARY NONE Difficulty urinating, kidney stones, other: MUSCULOSKELETAL NONE Severe back pain, severe joint pain, other: SKIN NONE Rash, MRSA, other: NEUROLOGICAL NONE Severe headaches, pain/numbness in legs, other: PSYCHIATRIC NONE Depression, anxiety, other: HEMATOLOGIC NONE Blood clots, transfusions, other: ENDOCRINE NONE High blood sugar, excessive thirst, other:

5 Baltimore Office on the St. Agnes Hospital Campus Angelos Medical Pavilion 3407 Wilkens Ave., Suite 410 Baltimore, MD Phone: // Fax: From Baltimore Beltway Exit 12 Wilkens Avenue East. Travel approximately 2 miles east. Turn right at the traffic light into the Campus of St. Agnes Hospital. The Angelos Pavilion is the building immediately to your left as you enter the campus. Park in Lot F, in front of the building. From Interstate 95 - Exit 50, north to Caton Ave. Travel north on Caton < 1 mile. Turn left at the light onto the Campus of St. Agnes Hospital. Wind through the Campus following signs for Angelos Medical Pavilion. The Angelos Medical Pavilion is the last building on the right before exiting hospital campus. Park in Lot F, in front of the building. Columbia Office between Howard County General Hospital and Howard Community College Medical Pavilion at Howard County Charter Drive, Suite 230 Columbia, MD Phone: // Fax: Local directions: From The Mall in Columbia drive westbound on Little Patuxent Parkway (Route 175). Continue past Howard County General Hospital and turn left onto Cedar Lane. Turn left onto Hickory Ridge Road. Turn left onto Charter Drive and continue to the MPHC, which is the second building on the right. From Route 32: Exit onto Cedar Lane and continue to Hickory Ridge Road. Turn right onto Hickory Ridge Road. Turn left onto Charter Drive and continue to the MPHC, which is the second building on the right. From all other points: Take Route 29 towards Columbia. Exit onto Broken Land Parkway toward Columbia Town Center/Merriweather Post Pavilion. Turn left onto Hickory Ridge Road. Turn right onto Charter Drive and continue to the MPHC, which is the second building on the right.

6 Financial Policy Maryland Surgeons Patient Financial Policy 1. We have outlined our financial policy below. If you have any questions about the policy, please discuss them with our Patient Accounting Department. We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. 2. Full payment of any amount that is your financial responsibility is due at time of service. For your convenience, we will accept VISA, Discover and MasterCard. 3. We have a participating agreement with many insurers and other health plans. We will bill those plans for whom we have an agreement and will require you to pay the designated co-payment at the time of service. 4. We will collect the co-payment when you arrive for your appointment. If your insurance plan requires you to have a written referral, we must have the referral before the service is rendered in order for the service to be covered. If the appropriate referral and/or co-payment are not present, the visit will be rescheduled, unless there is an immediate or urgent medical need for treatment. 5. As a courtesy, we will file your insurance claim for you with insurance companies with whom we do not have a participating contract. We will bill you directly for any patient liability; that is, applicable deductible, copays, coinsurance, etc. If your plan is not an HMO and your insurance company does not pay within six months from date of service, we will look to you for payment. 6. All health plans are not the same and do not cover the same services. In the event you do not have HMO coverage and your health plan determines a service to be "non-covered, you may be responsible for the complete charge. Payment is due upon receipt of a statement from our office. For services that are known to be non-covered by an HMO before they are rendered, you will be required to sign a financial responsibility form acknowledging your responsibility for payment. 7. If you wish to see our doctors for consultation and you are not covered by health insurance, all fees are to be paid at time of service. If you require surgery and you are not covered by health insurance, you must contact our Patient Accounting Department before the surgery will be scheduled to make payment arrangements. A deposit is required before the surgery. 8. Accounts not paid within our routine billing cycle of ninety-one days will be turned to collections. These accounts will be subject to additional fees collection fees, legal fees and interest. 9. If at any time, during the course of treatment your healthcare coverage changes, please notify us immediately. Each insurance plan has different requirements for authorization and precertification of services. Some insurance plans require that certain procedures be performed by particular providers or in certain facilities with whom they have contracted in order to be covered. It is essential that we have correct insurance information when scheduling any procedure for you. 10. If at any time you are unable to make payment of the amounts you have been billed, call us as soon as possible to discuss the situation in order to avoid unnecessary collection and legal costs. 11. There is a $35.00 fee for any returned checks. 12. There may be a $100 fee for cancellation of surgery, for reasons other than medical. U:MDSurgeons/Forms/Financial Policy 02/28/2012